minor“Some risk assessments lacked evidence of the person, or their family, having been involved in the process.”
moderate“One person's risk assessment for moving and handling said the person needed to be supported to get up from the floor. However, the risk assessment did not give detail of how this should be done.”
minor“Care plans contained aspects of person-centredness, although they required more detail to show what support was needed at each visit.”
record keeping
2 findings
minor“Daily records for people who had been assessed as nutritionally at risk did not always fully reflect the support staff had provided in this area.”
minor
“Two examples were discussed with the registered manager whereby changes to people's circumstances had not been reflected in care records. These changes were known to staff, but records had not been updated.”
consent capacity
2 findings
minor“Documentation needed to better evidence people's involvement in care planning and consent to support.”
minor“A mental capacity assessment was needed to formally record this and prompt a best interests assessment. The registered manager said they would follow this up.”
medication management
1 finding
moderate“Some Medication Administration Record (MAR) charts were in place for people who managed their own medicines but received occasional support from staff. Additional information needed to be added.”
staff competency
1 finding
minor“Staff had been trained in administering medication, although a formal competency check was needed in line with national guidance.”
governance
1 finding
minor“The registered manager told us they asked people and relatives for feedback about the service they received. However, this quality checking was not being recorded.”